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Nicotine addiction is a widespread public health issue. It affects millions of people worldwide and contributes to over 8 million deaths globally annually through smoking-related illnesses, with an additional 1.2 million deaths linked to secondhand smoke exposure.[1]
Despite the well-documented adverse health effects of smoking, many people find it extremely hard to quit due to withdrawal symptoms and cravings. This cycle of harm spotlights the need for evidence-based methods to support smoking cessation among those who want to or have to quit.
Among these methods, using nicotine replacement therapy (NRT) is a helpful, evidence-based, easy-to-follow, low-risk method for managing nicotine dependence.[3]
In this guide, we will take a closer look at an overview of nicotine addiction and the importance of evidence-based approaches, with a particular focus on the mechanisms, effectiveness, and practical applications of NRT as a strategy to overcome smoking addiction.
- NRT supports smoking cessation by delivering measured nicotine doses that ease withdrawal symptoms and cravings while avoiding the toxic chemicals in tobacco.
- NRT is available in various forms and formulations, such as patches for steady delivery, gum and lozenges for quick relief, and inhalers or nasal sprays for rapid craving management. Combining methods often improves success.
- These evidence-based strategies have demonstrated effectiveness: using NRT for 8–12 weeks (or longer if needed), combining long-acting and short-acting forms for better outcomes, and adapting medically-supervised strategies to meet individual needs for specific groups, such as pregnant individuals.
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What is Nicotine Replacement Therapy (NRT)
Nicotine is the primary addictive substance in tobacco products that drives smoking behavior.[2][4] It is, however, tobacco’s other components that cause the widespread illnesses and deaths related to smoking.[3] Therefore, in order to quit smoking, the emphasis should be on managing the response to the addictive substance, which is nicotine.
NRT is designed for people who want to quit smoking or must quit smoking, making this difficult process easier and more attainable. Abruptly discontinuing smoking, which is called quitting “cold turkey,” can trigger withdrawal symptoms and intense cravings. While quitting cold turkey is a strategy used by some people, not using any NRT can make the smoking cessation process quite challenging.[5] NRT uses a safer delivery method to provide a steady, controlled amount of nicotine to help manage withdrawal symptoms and cravings that may arise.[5]
The evidence that NRT helps to stop smoking is now well accepted. Many clinical guidelines recommend NRT as a first-line treatment for people seeking pharmacological help to stop smoking.[6]
Benefits of NRT
The benefits of seeking NRT include:[3][6]
- NRT helps increase the likelihood of quitting. Research demonstrates that NRT improves the chances of quitting smoking by 50–70%, as compared to quitting without assistance.
- NRT reduces the discomfort of nicotine withdrawal, including irritability, restlessness, and difficulty concentrating.
- NRT is safe and does not expose one to the harmful chemicals and substances in cigarettes that cause smoking-related diseases.
- NRT is flexible and comes in various forms, allowing people to choose a method or product that fits their needs and preferences.
- It is a step-down approach, meaning that NRT allows for a gradual reduction of nicotine levels, supporting a smoother transition to complete cessation.
How NRT works
Tobacco use is a leading cause of preventable death worldwide.[7] Many smokers want to quit but struggle to do so because of nicotine’s highly addictive nature. NRT can make smoking cessation a bit easier by providing a safer source of nicotine to reduce cravings and withdrawal symptoms. [7]
Research shows that NRT improves the chances of quitting smoking. Most studies suggest it makes success 50–70% more likely than quitting unaided, with some findings placing the improvement at 34–54%.[7] By offering options like patches, gum, and lozenges, NRT provides a flexible and effective way to reduce nicotine use and gradually achieve a smoke-free life.
Types of Nicotine Replacement Therapy
Several forms of NRT cater to different needs, including transdermal patches, acute-dosing products, and innovative therapies.[7]
Nicotine patches (Transdermal patches)
Nicotine patches deliver a steady dose of nicotine through the skin. They help reduce cravings by maintaining consistent nicotine levels in the body, making it easier to quit smoking gradually. Patches are available in different strengths, typically ranging in dosages from 5 mg to 21 mg over a 24-hour period.
How to use nicotine patches
- Apply a patch in the morning to a clean, dry area of your skin without much hair (can be placed below your neck, above your waist, or your upper arm or chest).
- Replace the patch daily, applying it to a different area each time to avoid skin irritation.
- Most people start with a 21 mg patch for several weeks, then gradually reduce to a 14 mg patch for another several weeks.
The FDA has approved using the patch for a total of 3 to 5 months, but using it longer (if necessary) may be safe and is better than going back to smoking. Talk to your healthcare team if you think you need to use the patch for longer.
Nicotine gum
Nicotine gum can be bought over the counter without a prescription. It delivers nicotine via the oral mucosa (the whole lining of your mouth) through intermittent chewing. Available in 2 mg and 4 mg forms, the higher dose is oftentimes more effective for heavy smokers. Acidic beverages can interfere with nicotine absorption and should be avoided before and during gum use.
How to use nicotine gum
Before using nicotine gum, carefully read the instructions provided within the package. It’s important to note that nicotine gum is not used like regular gum. Follow these steps for the best results:
- Chew the gum slowly until you notice a tingling sensation in your mouth.
- Place the gum inside your cheek and leave it there until the tingling fades.
- Chew it again to bring back the tingling, and then tuck it back into your cheek.
- Repeat this process for 20 to 30 minutes until the tingling sensation disappears.
Important
- Avoid eating or drinking anything for at least 15 minutes before and during gum use, as certain foods and drinks can reduce nicotine absorption.
- Chewing it like regular gum may prevent it from working properly.
- Use at least 9 pieces per day (every 1-2 hours) for the first 6 weeks, but don’t exceed 24 pieces per day. Nicotine gum is typically used for 6 to 12 weeks, and the maximum duration is 6 months.
- Gradually reducing gum use as you approach 3 months may help you stop altogether. But, in most cases, it is better to keep using the gum than to start smoking again.
Nicotine lozenges
Nicotine lozenges are a discreet option that slowly delivers nicotine through the buccal mucosa (the part inside your cheeks and lips) over 30 minutes. They are available in 2 mg and 4 mg strengths and are a good alternative to gum for those who prefer not to chew.
How to use nicotine lozenges
Nicotine lozenges can help manage cravings, but it’s important to use them correctly for the best results:
- Follow the recommended dosing schedule: weeks 1–6: Use one lozenge every 1 to 2 hours; weeks 7–9: Use one lozenge every 2 to 4 hours; weeks 10–12: Use one lozenge every 4 to 8 hours.
- To help ease withdrawal symptoms, try using at least nine lozenges daily for the first 6 weeks. If cravings occur, you can use more, but follow the usage limits below.
- Avoid eating or drinking for at least 15 minutes before and during use, as some drinks can make the lozenges less effective.
- Let the lozenge dissolve slowly in your mouth, usually taking about 20–30 minutes. Occasionally, move it from side to side while it dissolves.
- Do not bite, chew, or swallow the lozenge. The nicotine is absorbed through the buccal lining of your mouth.
- Only use one lozenge at a time as indicated, and don’t use them back-to-back.
- Stick to the maximum usage limits as described: No more than 5 lozenges in 6 hours, no more than 20 lozenges per day.
Nicotine lozenges are usually only recommended for 12 weeks. If you feel you need to continue using them after that, talk to your doctor.
Oral inhalers
Nicotine inhalers are prescription-only devices that mimic the hand-to-mouth motion of smoking, which can be helpful for people who miss that part of their smoking habit. They consist of a mouthpiece and a cartridge containing nicotine.
Each cartridge provides up to 4 mg of nicotine with frequent puffing, offering flexibility for cravings. However, minimal nicotine reaches the lungs. It is not the same as vaping and should not be confused with e-cigarettes, which are not FDA-approved as NRT.
How to use the nicotine oral inhaler
- Take short, shallow puffs to release nicotine vapor into your mouth.
- You can use a cartridge all at once over 20 minutes, or you can take short puffs throughout the day (5 minutes at a time).
- The typical dose is 6 to 16 cartridges per day, gradually tapering off over 6 months.
Safety Note
Used cartridges still contain nicotine and can be harmful to children or pets. Dispose of them safely and keep them out of reach.
Contact the Poison Control Center at 1-800-222-1222 immediately for assistance in case of exposure.
Nicotine nasal spray
Nicotine nasal spray is only available by prescription. It delivers rapid nicotine, which is absorbed through the nasal mucosa. Each dose consists of two prays, each delivering 1 mg of nicotine. This form of administration is fast-acting and helpful for cravings.
How to use nicotine nasal spray
- You are instructed to take 1–2 doses per hour, each consisting of 2 sprays (1 spray in each nostril). When you first start, you may need to take at least 8 doses (16 sprays) each day. Instructions may vary, so discussing your best plan with your healthcare provider is important.
- Do not use more than 40 doses (80 sprays) per day, as exceeding this limit can increase the risk of serious side effects. The FDA recommends not using nicotine nasal spray for more than 6 months. If you feel the need to continue, consult your doctor.
Safety note
Nicotine nasal spray can be harmful if it comes into contact with the skin or eyes. If this happens, wash the area immediately with water. Always store the spray safely away from children and pets.
Contact the Poison Control Center at 1-800-222-1222 immediately for advice and assistance.
Safety and side effects of NRT
Nicotine replacement therapy (NRT) is widely considered a safer alternative to smoking, as it provides nicotine without exposing users to the harmful chemicals found in tobacco smoke. [13] It is also a safer option for pregnant individuals, though consulting a healthcare provider before use is strongly advised. [14] Similarly, individuals with heart conditions or other medical conditions should seek medical guidance before starting NRT to ensure its safety and suitability for their specific needs.[10][20][3]
While NRT is an effective tool for quitting smoking, being informed about potential side effects and consulting with a healthcare professional can help ensure that its use is both safe and tailored to the individual’s needs.
Common side effects of NRT:
- Nicotine patches: These may cause skin irritation, redness, or itching at the application site.[15]
- Nicotine gum: This can lead to mouth soreness, hiccups, jaw discomfort, or gastrointestinal issues, like nausea.[16]
- Nicotine lozenges: Side effects include throat irritation, hiccups, heartburn, and nausea.[17]
- Nicotine nasal spray: Users report experiencing nasal irritation, runny nose, watery eyes, or coughing.[18]
- Nicotine inhalers: These may cause mouth or throat irritation and coughing.[19]
Serious risks:
Serious adverse health effects from NRT are rare.[14]
Nicotine poisoning
Nicotine poisoning, also known as nicotine overdose, occurs when a person is exposed to a dangerous amount of nicotine. This typically happens through high concentrations found in e-cigarette liquids, nicotine replacement products, accidental ingestion, or skin contact, particularly in children.[21]
Severe symptoms of nicotine poisoning may include seizures, difficulty breathing, irregular heart rhythms, and, in extreme cases, coma.[22] Additional signs of toxicity, such as nausea, vomiting, sweating, confusion, and muscle twitching, can intensify as nicotine levels rise in the body.[23]
If you suspect you or someone else has been nicotine poisoning, call 911 immediately or contact the Poison Control Center at 1-800-222-1222.
Who is NRT for
Nicotine replacement therapy (NRT) is designed to support various populations in reducing or quitting nicotine use. While the goal is often to follow 'best practice' guidelines for ideal outcomes, it’s crucial to acknowledge that real-world responses can differ, particularly when addressing substance use. Pragmatic approaches like harm reduction are essential for meeting individuals where they are and prioritizing health improvements.
They effectively minimize the risks associated with nicotine use, such as smoking-related illnesses, and enhance overall health outcomes—offering a far more constructive alternative to punitive measures. [8]
NRT is intended for the following groups of people:[4][9][10][11][12]
- Adults who smoke and want to quit
- Adolescents aged 12+ with severe nicotine dependence
- Pregnant smokers unable to quit through behavioral methods alone
- People with smoking-related illnesses (e.g., heart or lung disease)
- Users of non-cigarette nicotine products (e.g., e-cigarettes)
Combining NRT with other treatments for nicotine dependence
Combining NRT with other pharmacological treatments, such as varenicline or bupropion, has been explored to enhance smoking cessation outcomes. Several randomized trials have evaluated the combination of varenicline and nicotine patches, with two meta-analyses indicating that this combination was more effective than varenicline alone in promoting smoking abstinence at 3- and 6-month follow-ups.[24][25][26]
However, evidence regarding other forms of NRT in combination with varenicline is limited. A recent randomized trial assessed the efficacy of varenicline combined with nicotine lozenges and found higher self-reported abstinence rates at 6 and 12 months compared with varenicline alone.[27] Despite these promising secondary outcomes, the trial did not show a significant improvement in biochemically verified abstinence, which was the primary outcome. Moreover, no published studies to date have examined the combined impact of varenicline and oral NRT (such as lozenges or gum) on smoking cessation in a full-scale randomized trial, leaving gaps in the evidence for this specific combination.[24]
Studies on the combination of NRT and bupropion suggest that it is more effective than NRT alone, yet there is no significant advantage over bupropion alone.[28] This data clearly shows the need to tailor smoking cessation strategies to individual preferences and needs, as the benefits of combining therapies can vary depending on the specific treatments and outcomes measured, as well as person-specific factors.
Speaking to your provider about NRT options
Talking to a healthcare provider is an excellent first step in quitting tobacco. They can help you choose the best treatment, including medications and counseling, and they can recommend the right nicotine replacement therapy (NRT) or other quit medications for your needs.
Be sure to share relevant details, like how much you currently smoke, dip, or chew, what methods you've tried before and how they worked, and any medical conditions you have. This information will help your provider create a quit plan that fits your lifestyle.[29]
Here are some questions to ask your provider about medications:
- When should I start the medication?
- How long will I need to use it?
- How do I use it properly?
- What should I do if I slip and use tobacco while taking the medication?
- What are the side effects, and how can I manage them?
- Is this medication safe for me, given my medical history?
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